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Physician Associates:
An International
Perspective
Mary Ellen Gray, PA-C,
Professor David Martin, MD, FRCP
Lahey Hospital and Medical Center,
Burlington, Massachusetts
I have no disclosures…Just my
handsome dog
How it all began:
In the 1950s medicine became divided
into specialties as medical acumen grew
too large for the General Practitioner and
the General Surgeon
In 1957 Dr Eugene Stead tried to launch a
program at Duke University to train nurses
to deliver primary care…It was denied
accreditation
Dr Stead: We owe it all to him
Dr Stead turns to military
corpsmen
He observed the skills of military corpsmen and the
lack of primary care for rural populations. He
pitched the idea to Duke to train corpsmen as
primary care providers. Duke agreed. The first class
had 4 students. This was 1965.
1965: Medicare and Medicaid
are established
Lyndon Johnson was President. Now more Americans than ever before had health care coverage. The need for primary care providers became ever more pressing.
In the late 1960s, the AMA formally endorsed Physician Assistants.
A Precedent was established
1966: “People vs Whittier”:
An ex-Navy corpsman is sued for
practicing medicine without a license by
acting as assistant to a neurosurgeon. Dr.
Stead enrolled him at Duke. This case
highlighted the need for a licensure
pathway for non-physicians.
1967: Here we go!
Duke graduates its first class of PAs:
Victor Germino, Kenneth F. Fennell,
Richard J. Scheele
University of Alabama launches the first
Surgical Assistant Program
October 6 (Dr Stead’s birthday,
coincidentally) chosen as National PA Day
The AAPA was established in 1968
In 1970 Kaiser Permanente becomes the first HMO to employ PAs
More than 100 PA programs exist in the US but without standardization. Ultimately, a 2 year training model is adopted as the norm
Governor Ronald Reagan of California signs law formalizing PAs as licensed health care providers for the state
1970s: Growth
Individual states enact legislation governing
PA practice
AAPA opens an office and NCCPA is established
First certificates issued to PAs passing the
NCCPA exam
2 year certification cycle/6 year exam cycle
enacted
State PA chapters work toward persuading
legislation to sanction and grow PA practice.
Federal Government gets
involved:
1978: PAs appointed as commissioned
officers in the Air Force
Federal Government offers grants to PA
programs to train students
By 1980, 42 PA programs are accredited
by the NCCPA. 9431 certified PAs exist
1980’s: Firmly established
49 out of 50 states adopt PA practice
Prescriptive privileges the norm
Medicare allows for reimbursement of PA services
1983: PANCE exam formally adopted
1984: Canadian National Forces begin training and using PAs
1985: PANCE exam offered to informally trained PAs for the last time (“Grandfathered”)
1990s: Further growth.
By 1990, 45 accredited PA programs in the
US
21,194 nationally certified PAs (PA-C)
2000: Finally!
Mississippi becomes the final state to pass
legislation allowing PAs to practice in the
state
There are now 114 PA programs
There are 45,847 certified PAs in the US
Internationally: 2000 and beyond
2001: PAs introduced into the Netherlands
2002: PAs introduced into Canada, UK
2005: first PA program in the UK:
University of Wolverhampton. First class
of PAs graduate from the Netherlands.
First German PA program starts: Steinbeis
University, Berlin
2006: Scotland enrolls 12 PAs into a pilot
program developed by the NHS.
Back in the USA: Further development
2007:, the first doctorate degree (DScPA)
awarded at Baylor University for 18 month
ER residency
Indiana become the last state to allow PAs
to prescribe
2010: Obamacare!
The Affordable Care Act adds 30 million
Americans to the ranks of the insured. All are
needing health care!
148 PA programs
92,049 certified PAs
NCCPA adds exams for “Added Qualification”
(CAQ) for CT surgery, Nephrology,
Orthopaedics, Psychiatry.
Today:
PAs in Australia, Ireland, India, New
Zealand, South Africa, Bulgaria
220 US PA programs. Vast majority are
Masters Degrees
108,500 certified US PAs
PAs own their own practices and
employ MDs to supervise them
Challenges: We are recognized
but are we reimbursed/paid?
US has ”third party payers” – private insurance companies for people under age 65, working, not disabled. Insurance usually provided through employer. Some insurance companies do not reimburse for PA services
Services delivered by a PA must be billed under a supervising MD’s name
Under Medicare regulations, PA services are paid at 85% of the fee for MD services. Private insurers differ in approach (no coverage, 85%, or 100%)
Nurse Practitioners in the US have their own independent medical license making them easier to employ for billing purposes. Lots of jobs going to NPs for that reason alone
Unbillable services in the US
context:
How does the PA get credit for managing
patient care on the inpatient unit? For returning patient phone calls and managing care via telephone? For reviewing and refilling (or denying) prescription refills?
Much of what PAs do that keep the wheels of medical care delivery in smooth operation cannot be accounted for using “billable fee for service” model. Insurers, including Medicare, want documentation of all services for reimbursement
The challenges of success…be
careful what you wish for!
PA salaries are growing due to high demand. We have proven our value: high quality care comparable to care delivered by physicians. But will our swelling numbers eventually decrease demand and cause salaries to diminish?
If PAs and NPs take over the bulk of primary care, will primary care be even further devalued?
Salary caps: Hospitals are unaccustomed to paying PAs salaries commensurate with MDs regardless of the value the PAs bring to the institution
Glass ceiling: Not just for salaries, but also professional growth
Specialization: losing the ability to move between specialties in medicine and surgery if “special qualifications” become mandatory
About Lahey Hospital and
Medical Center
Lahey is an integrated group practice of approximately 600 MDs
Operating a 325 bed tertiary care hospital in greater Boston, and a 10 bed hospital/ambulatory clinic on the North Shore of Boston
21,000 discharges annually
1.2 million patient clinic visits annually
20,000 surgeries annually
70,000 emergency visits annually
A founding member of Lahey Health, an integrated healthcare delivery system including 2 additional community hospitals, community-based primary care behavioral health, home care and rehabilitation/nursing facilities
Affiliated with Tufts Medical School
Total number of APs at Lahey: 220
Total number of PAs at Lahey: 100
Total number of PA students completing clinical rotations at Lahey in 2015: 49
PA schools routinely sending students to Lahey for clinical rotations:
Northeastern University
Mass. College of Pharmacy
Tufts University
Boston University
Springfield College
University of New England
Lahey Departments with PAs on staff:
Cardiology
Cardiothoracic
Surgery
Colon-rectal Surgery
Emergency Medicine
General Internal
Medicine
General Surgery
Hospital Medicine
Neurology
Neurosurgery
Orthopedic Surgery
Pulmonary and
Critical Care
Radiology
Vascular Surgery
Progress at Lahey:
PAs will have their photos and bios included on Lahey
website for patients to view
PAs included in Medical Staff meetings, formerly
exclusively for physicians
PAs listed as primary care providers now that
Medicare recognition is formalized
PAs starting to be included on high level committees
formerly only open to physicians and administrators:
a voice for Advanced Practitioners institution-wide
Many thanks for your attention
Samira Al-Ayed,
computer enabler
Joanne Wozniak, PA-C
Danielle Callahan, PA-C
Stephanie Schifano, PA-C
Beth Doll, PA-C
Susan Stempek, PA-C
Carolyn Hamilton, PA-C
Rebecca Natale, PA-C
Giuseppe Sarno, PA-C
Ran Ku, PA-C
Robin Childress, PA-C
Tom McLaughlin, PA-C
Steven Noiseux, PA-C
And thanks to: